Original Article FOR A DISTAL RADIUS FRACTURE THAT HAS UNDERGONE A SATISFACTORY CLOSED REDUCTION? Khalid Masood *, Muhammad Jamil **, Farooq Ibrahim Pasha*, Khalid Zulfiqar Quresshi **, Naveed Ishaq Malik * * Consultant Orthopedic Surgeon, CMH, Lahore. ** Consultant Surgeon, CMH, Lahore. Objective: To evaluate the radiographic outcome in fractures of the distal radius treated with closed reduction and plaster casting. Design: A retrospective study Setting: Hand and Upper limb Surgery Centre and Combined Military Hospital Lahore Pakistan. Patients: Forty three patients (31 males, 12 females, aged 18-75 years), with fractures of distal radius were seen between January 2011 and December 2011. Interventions: Closed reduction and plaster casting of fractures, followed up by good-quality postero-anterior and lateral radiographs to evaluate stabilization and healing. Main outcome measures: Radial height (length), radial inclination and volar (palmar) tilt were measured on radiographs obtained preoperatively, immediately postoperatively, and at the time of removal of plaster cast. Data were analyzed by the t-test. Results: There was an acceptable improvement in the measurements of radial height and radial inclination immediately after closed reduction and stabilization with plaster cast. This improvement was gradually lost and height and inclination were significantly decreased by the time plaster was removed. Improvement in volar tilt was not significant. Results were poor in AO type B and C and acceptable in AO type A fractures. Conclusion: Closed reduction and plaster casting is a common method to deal with bone fractures but cannot effectively protect comminuted distal radial fractures from loss of reduction, which may be associated with shortening and re-displacement and malunion. Keywords: Distal Radius fracture, close reduction for Radial fracture, Malunion in fracture radius. INTRODUCTION Fractures of the distal radius are extremely common. These fractures give uniformly good Corresponding Author: Dr. Khalid Masood, Consultant Surgeon, Lahore Cantt. E-Mail: kmasoodsurg@hotmail.com results and the standard of treatment for most distal radial fractures has been closed reduction and immobilization 1, 2. Although the injury is predominant in the elderly which usually of low energy, but recently,because of motor vehicle accidents and recreational activities, there has been an increase in the number of high-energy fractures of the distal JUMDC Vol. 4, Issue 1, Jan-June 2013 1
radius seen in young adults, resulting in surgical management of these injuries 3. Restoration of normal alignment and articular congruity after a displaced fracture can be difficult but is essential for a good functional result 4, 5. Extra-articular and intra-articular malunion have both been shown in the laboratory 4 and in clinical studies 6, 7, to alter function and the patient s satisfaction with treatment outcome. Closed reduction and casting as the only option of treatment may result in inability to manipulate displaced or depressed articular fragments 8. This technique misses associated soft-tissue and ligamentous injuries, which are being recognized with increasing frequency 9, 10. The purpose of this study was to determine the radiographic outcomes of acute fracture of the distal radius, treated with close reduction and immobilization in cast. MATERIALS AND METHODS Study design: This was a retrospective study of 43 consecutive patients having distal radial fractures, treated by closed reduction and POP cast immobilization at two institutions who were followed up until the fracture was united and the POP cast was removed. The study design included the evaluation of plain radiographs made at the patient s initial visit (pre-operatively), immediate postoperatively and at the time of removal of POP cast. Patients: 43 consecutive patients (31 males, 12 females) with distal radial fractures were treated by closed reduction and POP cast immobilization in Hand and Upper Limb Surgery Centre and Combined Military Hospital Lahore for a period of one year from January to December 2011. Three surgeons were responsible for that procedure. Patients with open or complicated fractures, who had undergone closed reduction and external fixation or who had associated multiple injuries were excluded from the study. The mean age at the time of the injury was 39 years (range from 18 to 75 years). The mean and standard deviation [SD] ages were 52.4± (9.8) years for female patients and 39± (8.8) years for male patients. Twenty six fractures occurred on the left side and 17 fractures occurred on the right (Table 1). Table: 1 Clinical Data for 43 Patients: Having Distal Radial Fractures treated by Closed Reduction and Cast Immobilization. Side of fracture Left 26 Right 17 Age, yr No. of patients 15 20 05 21 30 07 31 40 19 41 50 06 51 60 03 61 70 02 71 80 01 Classification of fractures: All fractures were classified according to the Association for Osteosynthesis (AO) 11 with the help of posteroanterior and lateral radiographs of the wrist made at the time of the initial injury and after the reduction. According to this classification, most of the cases were of B and C type probably because of increased incidence of high velocity injuries. (Table 2) Table: 2 Types of fracture Type of fracture Frequency Percent Valid Percent A2 2 4.7 4.7 A3 4 9.3 9.3 B2 1 2.3 2.3 B3 11 25.6 25.6 C1 7 16.3 16.3 C2 11 25.6 25.6 C3 7 16.3 16.3 Total 43 100.0 100.0 Operative treatment: Overall, closed reduction and cast immobilization were performed a mean (and SD) of 2.5 (3.2) days (range from 0 to 14 days) after the injury. All operations were performed under fluoroscopic surveillance. (Table 3) 2 JUMDC Vol. 4, Issue 1, Jan-June 2013
Table:3 Day of Operation Day of operation Frequency Percent Valid Percent Cumulative Percent.00 3 7.0 7.0 7.0 1.00 19 44.2 44.2 51.2 2.00 7 16.3 16.3 67.4 3.00 3 7.0 7.0 74.4 4.00 3 7.0 7.0 81.4 5.00 4 9.3 9.3 90.7 6.00 1 2.3 2.3 93.0 7.00 2 4.7 4.7 97.7 14.00 1 2.3 2.3 100.0 Total 43 100.0 100.0 Radiographic evaluation: test. Statistical significance was defined as p < 0.05. To evaluate distal radial fractures posteroanterior (PA) and true lateral radiographs were obtained. All imaging studies were assessed in a blind fashion by 2 independent investigators, and the 2 measurements were averaged. PA view provided information about radial height and inclination. Normal Radial height is 11mm and was measured as the distance between 2 lines perpendicular to the long axis of the radius, one drawn at the tip of the radial styloid and another drawn at the distal ulnar articular surface. Normal Radial inclination is 22 degrees and it was measured as an angle formed between a line drawn through the tip of the radial styloid and the medial corner of the lunate facet and a line drawn perpendicular to the long axis of the radius. In the lateral view, the volar tilt of the distal radial articular surface was measured 12, 13. Its normal value is 11 degree. These measurements were taken at three stages. Initial X-rays before reduction followed by at two stages of treatment (immediately postoperatively and at the time POP cast was removed). Analysis of the data: The differences between various measurements were evaluated by Student s t- Table: 4 Measurement stages RESULTS Radiographic evaluation in different stages of management: Distal radial deformity was assessed by measuring radial height, radial inclination and volar tilt at different stages of treatment. There was improvement in Radial height in initial postoperative stage but the reduction was lost by the time POP cast was removed and was only minimally better than initially. Similarly the radial inclination was improved just postoperatively but had decreased by the time of removal of POP cast (Table 4, p < 0.05 for all comparisons). The volar tilt of the distal radius improved from an average of 1.42 to an average of 0.65 at the immediate postoperative evaluation, then remained persistent at 0.53 at the time POP Cast was removed. No significant difference was noted between the initial visits before reduction, immediately postoperatively and after removal of the POP cast (Table 4, p > 0.05 for all comparisons). stage R.H (mm) R.I (degrees) V.T(degrees) Mean SD Mean SD Mean SD Pre-op 7.98 2.4 17.63 3.5-1.42 7.50 Post-op 10.33 1.7 19.39 3.6.65 7.7 ROC 9.15 2 18.8 3.2.53 2.5 RH= Radial Height, R.I= radial Inclination, V.T= Volar tilt, ROC= removal of Cast JUMDC Vol. 4, Issue 1, Jan-June 2013 3
Effects of Type of fracture: Radial height and Inclination were improved in type A. But type B and C fractures of the distal radius did not show the correction effect of radial height and inclination (Table 5, 6). Effects of type of Fracture: Similarly Volar tilt was improved after correction of type A and fracture (Preop- Postop period) but was lost significantly by the time cast was removed. So the net improvement was negligible (Preop-ROC period) (Table 5, 6). Table: 5 Preop-Post Op stage. Improvement on the basis of type of fracture Type of Fracture R.H (mm) R.I (degrees) V.T(degrees) Mean SD Mean SD Mean SD A 2.7 3.02 5.75 3.5 3.24 3.4 B 2.43 3 4.80 3.7 1.81 3.5 C 1.85 3.1 4.1 3.6.62 3.6 RH= Radial Height, R.I= radial Inclination, V.T= Volar tilt, ROC= removal of Cast Table: 6 Preop-ROC Stage. Net Improvement Type of Fracture R.H (mm) R.I (degrees) V.T(degrees) Mean SD Mean SD Mean SD A 1.35 1.9 2.16 4.26 2.94 4.4 B 0.77 2.17 0.61 6.98 1.38 3.8 C 0.1 4.51 0.52 7.13-1.18 7.6 RH= Radial Height, R.I= radial Inclination, V.T= Volar tilt, ROC= removal of Cast DISCUSSION Closed reduction with cast treatment of all types of distal Radius fractures continues to be the mainstay of treatment in our country. Studies have shown that in distal radial fractures function is related to the radiographic findings 2. Intra or Extraarticular malunited fractures have been shown to alter function and patient satisfaction with the outcome of treatment. In a study Arora R et al mentioned an obvious clinical deformity in 77% of cast group and malunion occurred in 89% primarily reduced fractures 14. Evidence in the literature indicates a strong correlation between restoration of bone anatomy and recovery of function 15, because the position of the fracture at the time of union rather than the position at the time of presentation has the greatest correlation with long-term functional results 16. The purpose of this study was to establish the stabilization effect of casting on fractures of the distal radius. As we have noted, the bony deformity of the distal radius showed improvement in measurements of radial height and inclination immediately after reduction (Table 4), while restoration of volar tilting of the distal radius was not well achieved with POP casting (Table 4). Assessment of type of fractures was vital to predict the outcome of management. Comminuted intra-articular fractures of distal radius are very difficult to manage. Severe comminution is associated with shortening and re-displacement 12. Rozental TD et al showed satisfactory results with closed reduction and pin fixation for unstable distal radial fractures 17. Another study mentioned reasonably nice data for extra-articular fractures reduced in dorsally flexed position then immobilized in casting 13. We found that Intra-articular fractures i.e Type B and C treated by cast Immobilization negligibly improve the radial height, radial inclination and volar tilt (Table 5,6). Fractures with less comminution got more correction after application of POP Cast, while this 4 JUMDC Vol. 4, Issue 1, Jan-June 2013
correction was lost gradually by the time it was removed (Table 6). This corresponded to the viscoelastic characteristics of ligaments. Strong palmar ligaments have been shown to become taut and limit radio-carpal distraction, while the weaker, Z-shaped dorsal ligament complex has yet to reach maximum length 18. This prevents longitudinal traction alone from restoring volar tilt and may explain why the volar tilt of the distal radius deformity did not improve significantly with POP cast immobilization (Table 6). For distal radial fractures, a high frequency of ligamentous injuries is commonly associated with both intra-articular and extra-articular fractures 18. These are the factors involved in the development of redisplacement even after satisfactory reduction and fixation with K- wires 19. The plain radiographs were probably inadequate to identify acute ligamentous injuries. Even if no ligamentous injuries existed coincidentally and the distal radial fractures were well reduced at the time of initial management, the stretched ligaments will gradually become deformed and the stress relaxed, followed by re-displacement of well reduced fractures as proved in our study. However conservative measures are acceptable even with disability in elderly people and patients with dementia or multiple medical co-morbidities 20. CONCLUSIONS There is increased tendency of young patients to sustain comminuted distal radial fractures due to high energy trauma. POP cast is a popular method that may improve the reduction of type B and C fractures but can not assure the maintenance of reduction. Reduction of distal radial fractures cannot be achieved and maintained reliably using POP cast alone. Most patient suffering from distal radial fractures of Type B and C treated conservatively with POP cast fall into malunion. Although we can achieve better results in type A fractures by careful conservative measure (POP cast) that is well tolerated in older patients, but one must seek better and advanced measures to correct the deformity in more comminuted fractures particularly in young patients. REFERENCES 1. Salvi AE. The hand shake technique: proposal of a closed manual reduction technique for Colles wrist fracture. Am J Emerg Med 2011; 29:115-7 2. Handoll HH, Huntley JS, Madhok R. External fixation versus conservative treatment for distal radial fractures in adults. J Bone joint Surg AM.2008 Feb; 90(2): 451-4 3. McQueen MM, Hajducka C, Court-Brown CM. Redisplaced unstable fractures of the distal radius: a prospective randomized comparison of four methods of treatment. J Bone Joint Surg [Br] 1996; 78:404-9 4. Short WH, Palmer AK, Werner FW, Murphy DJ. A biomechanical study of distal radial fractures. J Hand Surg [Am] 1987; 12:529-34 5. Ejaz A M. Closed reduction and POP immobilization for Colles fracture under haematoma block and sedation as day care. Pak Armed Forces Med J 2012; 62(3):328-332 6. Fiql M et al. Volar fixed angle plate osteosynthesis of unstable distal radius fractures: 12 months results. Arch Orthop trauma Surg.2009 May; 129(5):661-9 7. Adams BD. Effects of radial deformity on distal radioulnar joint mechanics. J Hand Surg [Am] 1993; 18:492-8 8. Aro HT, Koivunen T. Minor axial shortening of the radius affects outcome of Colles fracture treatment. J Hand Surg [Am] 1991; 16:392-8 9. Axelrod T, Paley M, Green J, McMurtry RY. Limited open reduction of the lunatefacet in comminuted intra-articular fractures of the distal radius. J Hand Surg[Am] 1988; 13:372-7. 10. Fernandez DL, Geissler WB. Treatment of displaced articular fractures of the radius. J Hand Surg [Am] 1991; 16:375-84 11. Clayton RA, Gaston MS, Ralston SH. Association between decreased bone density and severity of distal radial fractures. J Bone Joint Surg AM 2009 Mar1; 91(3):613-9 JUMDC Vol. 4, Issue 1, Jan-June 2013 5
12. Germaine GQ Xu, Siew Pang Chan, Mark Edward Punhaindran, Winston YC Chew. Prosspactive Randomised Study of Intra- Articular Fractures of Distal Radius: Comparison between External and Plate fixation.annals Academy of Medicine 2009 July: 7(38):600-05 13. Sunil Rajan, Saurbah Jain, A Ray. Radiological and functional outcome in extra-articular fractures of lower end radius treated conservatively with respect to its position of immobilization. Indian J Orthop.2008 Apr-Jun; 42(2)201-207 14. Arora R et al. A comparative study of clinical and radiologic outcomes of unstable colles type distal radius fractures in patients older than 70 years: non operative treatment versus volar locking plating. J Orthop Trauma 2009 Apr; 23(4):237-42 15. Rauis A, Ledoux A, Thiebaut H, Van der Ghinst M. Bipolar fixation of fractures of the distal end of the radius. Int Orthop 1979; 3:89-96 16. Sheng Jui et al. Extra-articular deformity in distal radial fractures treated by external fixation. Canadian Journal of Surgery 2001 Aug; 4(44):289-94 17. Rozental TD et al. Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A prospective randomized trial. J Bone joint surg AM.2009 Aug; 91(8)1837-46 18. Bartosh RA, Saldana MJ. Intraarticular fractures of the distal radius: a cadaveric study to determine if ligamentotaxis restores radiopalmar tilt. J Hand Surg [Am] 1990; 15:18-21 19. Luscombe KL, Chaudhary S, Dwyer JS. Selective Kirschner wiring for displaced distal radial fractures in children. Acta Orthop Traumatol Turc. 2010; 44(2):117-23 20. William G Blakeney. Stabilization and treatment of Colles fractures in elderly patients. Clin Interv Aging.2010; 5:337-344 Submitted for publication: 22-02-2013 Accepted for publication: 20-03-2013 After minor revisions YOUR SUPREMACY OVER OTHERS IS IN PROPORTION TO THE EXTENT (size) OF YOUR KNOWLEDGE AND WISDOM. Hazrat Ali (Karmulha Wajhay) PERFECT HAPPINESS COMES WITH KNOWLEDGE, AND PARTIAL HAPPINESS COMES WITH ABSTINENCE (control, forbearance, ZUHD), WORSHIP WITHOUT KNOWLEDGE AND WITHOUT ABSTINENCE MERELY EXHAUSTS THE BODY. Hazrat Ali (Karmulha Wajhay) 6 JUMDC Vol. 4, Issue 1, Jan-June 2013